1. Neonatal Orthopedic Issues
Mikelle Key-Solle, MD
May 22, 2006

2. Objectives
Recognize common orthopedic issues which present in the neonatal period
Generate appropriate differential diagnoses
Identify appropriate interventions from a general pediatric perspective

3. Overview
Cased-based discussion of five of the more common neonatal orthopedic and musculoskeletal conditions
Typical physical exam findings
Management strategies
When to consult an orthopedic surgeon

4. Case 1 You are examining a 3 hour old term male infant
Mother had unremarkable pregnancy and delivery with normal prenatal labs
Infant appears nondysmorphic with a normal exam except for the following feet findings:

5. Case 1

6. Case 1: Metatarsus Adductus
AKA Metatarsus varus
Hindfoot normally positioned, but forefoot adducted
Flexible versus non-flexible
85% spontaneously resolve
Gentle stretching exercises may help

7. Metatarsus Adductus
If does not spontaneously resolve, can lead to classic foot deformity
Sole crease
Lateral bony prominence
May require shoes, casting

8. Time for Trivia
What is the origin of the phrase “getting off on the wrong foot”?
Putting the left foot down on the floor first when getting out of bed

9. Case 2 You are examining a 3 hour old term male infant
Mother had unremarkable pregnancy and delivery with normal prenatal labs
Infant appears nondysmorphic with a normal exam except for the following feet findings:

10. Case 2

11. Talipes Equinovarus AKA Clubfoot
Malalignment of the talocalcaneal, talonavicular and calcaneocuboid joints

12. Talipes Equinovarus
Fixed plantar flexion (equinus) of the ankle (talipes)
inability to bring to foot to a plantigrade (flat) standing position
Inversion/adduction
of the heel (varus)
Metatarsus adductus

13. Talipes Equinovarus 2:1 male to female 50% bilateral
Usually idiopathic
More severe if associated with neurological, connective tissue, or mechanical conditions

14. Talipes Equinovarus Requires urgent orthopedic referral
Treated using Ponseti method of serial casting +/- Achilles tendon release
Followed by nighttime bracing for 2 years
Outcomes typically very good

15. Summary Case 1: Metatarsus Adductus Case 2: Talipes Equinovarus
Forefoot adduction; most spont resolve
Case 2: Talipes Equinovarus
3 components; early ortho referral
Case 3:
Case 4:
Case 5:

16. All had congenital clubfoot treated with Ponseti method
Time for Trivia
What do Kristi Yamaguchi, Mia Hamm, and Troy Aikman all have in common?
All had congenital clubfoot treated with Ponseti method

17. Case 3
You are examining a 4 week old term female, born by c-section (breech)
NBN course unremarkable
Parents report infant seems to prefer keeping head tilted towards the right shoulder

18. Case 3 What do you expect to find on physical exam?
What is a common association with this condition?

19. Congenital Muscular Torticollis (CMT)
AKA “wryneck”
Unilateral deformity of the sternocleidomastoid (SCM) muscle resulting in chin pointing away and head tilting towards the affected side
Within first few weeks, may be able to palpate a firm, non-tender SCM mass

20. CMT
Associations:
80-90% with contralateral plagiocephaly and ipsilateral facial flattening
20% with hip
dysplasia

21. CMT Differential diagnosis: 3 categories Osseous
Klippel-Feil syndrome, congenital scoliosis
Non-osseous
Sandifer syndrome
Neurogenic
CNS tumors, Chiari malformation
Ocular torticollis
Paroxysmal torticollis

22. CMT

23. CMT Treatment consists of passive stretching
PT referral by 2-3 months if >10° dec ROM
85% will correct by 18 months
Persistence after 18 months warrants orthopedic referral

24. Summary Case 1: Metatarsus Adductus Case 2: Talipes Equinovarus
Forefoot adducted; most spont resolve
Case 2: Talipes Equinovarus
3 components; early splinting
Case 3: Cong. Muscular Torticollis
Head tilt; SCM mass early; stretching
Case 4:
Case 5:

25. Time for Trivia (or maybe just “triviality”)

26. Case 4
You are examining a 3 hour old term male born by c-section for failure to progress
Mother’s history is significant for bilateral clubfoot s/p correction, s/p pelvic stabilization surgery, malignant hyperthermia, and rheumatoid arthritis; father healthy

27. Case 4 Infant exam remarkable for
Diffuse hypertonicity and limited ROM
Bilateral finger and toe deformities, ulnar deviation of fingers
Bilateral elbow extension, forearm pronation
Bilateral flexion deformity of knees
Bilateral clubfoot
Few skin creases over joints

28. Case 4

29. Arthrogryposis Multiplex Congenita (AMC)
Collection of >150 conditions leading to >2 joint contractures
Non-progressive
Fibrosis of connective tissue and muscle
Etiology unknown, multifactorial

30. AMC Etiologic categories: neurologic vs. non-neuro Neuropathic
Amyoplasia
Meningomyelocele
Spinal muscular atrophy
Muscle abnormality
Cong muscular/myotonic dystrophy, myasthenia
Intrauterine myositis
Mitochondrial disorders
Connective tissue abnormality
Dwarfism
Multiple pterygium syndorme
Distal arthrogryposis
Intrauterine abnormality
Limited fetal space
Vascular compromise

31. AMC Only 30% genetic Most common form is amyoplasia (40%)
All forms of inheritance
Examples: Trisomy 18/21, Holt-Oram, Mobius, nemaline myopathy, Zellweger, Pfeiffer, Poland
Most common form is amyoplasia (40%)

32. AMC: Amyoplasia shoulder--internal rotation deformity
elbow--extension and pronation deformity
wrist--volar and ulnar deformity
hand--fingers in fixed flexion, and thumb-in-palm deformity
hip--flexed, abducted and externally rotated, often dislocated
knee--flexion deformity
foot--clubfoot deformity

33. AMC Associations Typically normal intelligence Midface hemangiomas
Scoliosis
Growth retardation
Abdominal hernias
Typically normal intelligence

34. AMC Cause determines prognosis Early orthopedic referral necessary
If neurologic deficit, brain/spine MRI
If dysmorphic features, karyotype and genetics consult
Early orthopedic referral necessary
Non-surgical measures used in neonatal period
Splinting/casting
PT and ROM exercises

35. Summary Case 1: Metatarsus Adductus Case 2: Talipes Equinovarus
Forefoot adducted; most spont resolve
Case 2: Talipes Equinovarus
3 components; early splinting
Case 3: Cong. Muscular Torticollis
Head tilt; SCM mass early; stretching
Case 4: Arthrogryposis Multiplex Congenita
Multiple contractures; neuro vs non-neuro; amyoplasia most common; splinting/casting in neonatal period
Case 5:

36. More Triviality

37. Case 5
You are examining a 4 week old term female born by c-section (breech)
NBN course was unremarkable
Parents have no concerns
Growth parameters all 50%th percentile

38. Case 5
Previous exam revealed a right hip click with Barlow maneuver, but now this has progressed to a “clunk”
What are Barlow and Ortolani maneuvers?

39. Case 5: Barlow and Ortolani
Infant must be relaxed
Examine one hip at a time
Hip flexed 90°, gentle manipulation
Barlow=Back + adduction
Ortolani=Out + anterior
Positive if “clunk”
palpable/heard

40. Case 5
What additional physical exam findings would suggest hip dysplasia?
Asymmetric gluteal/thigh folds
Leg length discrepancy (3-6 months)
Limited hip abduction (3-6 months)

41. Developmental Dysplasia of the Hip (DDH)
Definitions
Dysplasia: abnormal formation/development of hip joint
Subluxated: Femoral head is partially out of proper articulation with acetabulum
Dislocatable: ability to force femoral head out of articulation with acetabulum
Dislocated: femoral head is not articulating normally with the acetabulum at baseline

42. DDH
DDH recently coined due to the progressive nature of the problem, ie. Many hips normal at birth, but become unstable during the ensuing weeks/months

43. DDH Why worry? Premature degenerative joint disease Impaired walking
Chronic pain

44. DDH What other historical factors would increase your suspicion?
Breech female: 20 per 1000
FHx + female: 12 per 1000
Female, no risk factors: 5 per 1000
Breech male: 4 per 1000
Male, no risk factors: 0.3 per 1000
Bache CE, Clegg J, Herron, M. Risk factors for developmental dysplasia of the hip: ultrasonographic findings in the neonatla period. J Pediatr Orthop B. 2002; 11:

45. DDH Screening controversy
No direct evidence that screening improves functional outcomes
Studies show ↓, unchanged, and  rates of surgery among screened infants
Variable definitions of “positive”
No gold standard
Poor quality evidence for effectiveness of both non-surgical and surgical treatments

46. DDH X-ray Femoral head does not ossify until 3-6 months
Radiographic outcomes have not been shown to be valid or reliable surrogate for functional outcomes

47. DDH
Ultrasound
High false positive rate (ie. high rate of non-pathological hip findings)
Intraobserver reliability moderate
Interobserver reliability fair
May decrease unnecessary treatment when compared to clinical exam alone
Reliability of classification is questionable

48. DDH AAP recommendations from 2000 still stand
Screen during newborn period and each subsequent WCC with physical exam
If exam findings abnormal or breech female, obtain ultrasound at 1 month or when detected thereafter

49. DDH If pt deemed to have possible DDH, ortho referral recommended
Initial treatment non-surgical
typically Pavlik harness, which has been shown
to reduce rate of AVN

50. DDH Pavlik harness less successful: Bilateral DDH True dislocation
Age >8 weeks at initiation
Atalar H, Sayli U, Yavuz OY, et al. Indicators of successful use of the Pavlik harness in infants with DDH. Int Ortho. Apr 2006; (epub ahead of print).

51. Summary Case 1: Metatarsus Adductus Case 2: Talipes Equinovarus
Forefoot adducted; most spont resolve
Case 2: Talipes Equinovarus
3 components; early splinting
Case 3: Cong. Muscular Torticollis
Head tilt; SCM mass early; stretching
Case 4: Arthrogryposis Multi. Congenita
Multiple contractures; neuro vs non-neuro; amyoplasia most common; splinting/casting in neonatal period
Case 5: Developmental Dysplasia of Hip
Screen at every WCC +/- ultrasound; ortho referral if +; Pavlik harness highly successful

52. References
Alfonso, I, Papazian O, Paez JC, and Grossman, JA. Arthrogryposis Multiplex Congenita. International Peds. 2000; 15(4):
Freed SS, and Coulter-O’Berry C. Identification and Treatment of congenital muscular torticollis in infants. Jour of Pros and Ortho. 2004; 16(45):18-23.
Hulme A. The management of congenital talipes equinovarus. Early Human Development. 2005; 81:
Shipman SA, Helfand M, Moyer VA, and Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006; 117:
Weiner DS. Pediatric Orthopedics for Primary Care Physicians, Second Edition. New York, NY: Cambridge University Press; 2004